Let's Talk: American Racism Through the Lens of COVID-19

The Aspen Institute Health Innovators Fellowship | Health, Medicine, and Society Program

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Let’s Talk: American Racism Through the Lens of COVID-19 Virtual Convening July 7, 2020

The Aspen Institute Health Innovators Fellowship | Health, Medicine and Society Program

Let’s Talk: American Racism Through the Lens of COVID-19 Virtual Convening July 7, 2020 12:00 PM–1:15 PM

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Let’s Talk: American Racism Through the Lens of COVID-19

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00:06:06 Maria Hinojosa: So how are you doing personally?

Raegan McDonald-Mosley: Thank you for the question. I appreciate the opportunity to just check in and clear the slate. It’s a tumultuous time for everyone right now, and especially for people of color in the United States.

I would say right now, I have a lot of mixed feelings, because of what’s going on, both with the coronavirus and the state of social injustice around the country, but I’m also super hopeful because I feel like for the first time right now, eyes are opening. Those of us who’ve been working in this space have been well aware of the consequences of racism, both in the health care system and outside of the health care system for a long time, but now it feels like our neighbors for whom maybe that wasn’t their central issue are waking up to this reality. And for that reason, I’m hopeful.

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00:07:20 Thomas Fisher: There’s been a conversation around race and health care for about 50 years, and there’s reams published. We’ve had conversations and IOM reports that have been brought to the fore, and we’ve done very little about it. And, in fact, we’ve gone backwards on a lot of measures. What’s interesting about COVID is, in the setting of social distancing, being in the emergency department is the only place where I feel sort of normal. It’s the only place where I have social interactions with people, even though we’re masked and PPEed, but interactions that seem familiar to the time before.

The rest of society doesn’t look familiar at all. And in some ways, it makes me feel more optimistic. Particularly the protests look very different than they have in the past. We have people in all 50 states standing up against This is a lightly edited and shortened transcript of the webinar “American Racism Through the Lens of COVID-19,” which was held on June 10, 2020, as part of the “COVID-19: Health Care at an Inflection Point” series. The panelists have not reviewed this document. The full discussion is available online at https://www.aspeninstitute.org/events/american-racism-through-the-lens-oncovid-19/ 1

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police brutality. We’ve never seen that before. I was out at the protest during the Laquan McDonald situation in Chicago when a police officer murdered a young man and the video was suppressed for many years. Those protests were mostly black folks; these protests are mostly white folks. That gives me a level of optimism that I haven’t seen before. So even though things feel very different and uncomfortable in our daily lives because of a number of different reasons, there’s a lot of opportunity to look at silver linings and identify how we can build on this opportunity to a new future.

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00:10:07 Raegan McDonald-Mosley: We were not surprised. In fact, when people were saying, “Oh, this is the great equalizer. It does not discriminate.

Everyone’s at risk,” we knew from the very beginning of this outbreak in our nation that people of color would be disproportionately impacted. Because the reality is, is that racism is inherently built into all of our institutions, including the health care institutions, including where people live, where they get their food, things that impact their health, transportation. So we knew from the very beginning of this, but it took a while for people to start reporting the data about this.

I myself have been thinking about these issues for a long time, and it transcended for me from a professional interest to a personal one, unfortunately, three years ago when a dear friend of mine, Dr. Shalon Irving, died three weeks after having her first child. Shalon’s death garnered a lot of attention because of who she was in society. She was a highly educated black woman who worked for the CDC doing health equity work. Her death struck so many people, especially black women, as they thought, “If this could happen to her, it could happen to any of us.” And for those people in the public health and health care system space who read about Shalon’s death, it forced them to confront the fact that black women are three to four times more likely to die from pregnancy than white women, and this difference subsists even after controlling for things that we usually think of as protective: education, income, etc. And there have been many activists and providers who have been working in the reproductive justice space and maternal health space, namely Joia Crear-Perry, who’s the founder of the National Birth Equity Collaborative, who’ve been working to garner attention and traction on this matter and impact policies and operational changes that could reduce the numbers of black women that are needlessly dying.

So in this moment right now, where our nation, we’re finally reckoning with the insidious role that racism has played in our institutions and

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communities, it’s a bit frustrating, because we have known that racism had these impacts for a long time. And while we were able to ignore this 7-800 women who died from childbirth every year, it’s really hard to ignore 110,000 people who’ve died from the coronavirus. In my opinion, black women were the canary in the coal mine, and if we had been paying attention all along, perhaps we would not be in this place where so many people have needlessly died and disproportionately people of color.

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00:14:08 Thomas Fisher: Yeah, I mean, why would this be any different. Everywhere in health care we find black folks and brown folks have worse outcomes and worse health care in the same health care settings. And so, one should expect this to hold form. There wouldn’t be any reason why it would be different.

I first became aware of COVID coming I think it was New Year’s Eve because media in Europe began notifying on Twitter that there was a new virus coming, and I pay close attention to those things because in the emergency department we see an unfiltered section of society, and so when it shows up, it’s going to walk into my emergency department without announcing, “Oh, this is Ebola, this is smallpox, this is the coronavirus.” So at that time, I began following it, and I had suspicions that when a pandemic comes to Chicago, it may not be this, but this is how it starts, this is what it looks like.

And it began building steam.

While I knew that it would first be travelers, I also take care of people on the south side of Chicago, a black community that’s very old, that’s built from folks who traveled up from the south during the Great Train Migration fleeing terrorism, who birthed Mahalia Jackson and Richard Wright and Barack Obama, and who have experienced the short end of the stick for decades.

And in my community, we have a high rate of disability. So in Washington Park, 15% of folks are disabled compared to 4% in the Loop, and black mothers in Woodlawn, which is right nearby, give birth to low-birthweight babies 3.5% of the time compared to just 1% of the time in Lincoln Park. In Inglewood, which is a neighborhood that is wracked with handgun violence, you see the life expectancy is 59 years compared to over 80 in the Gold Coast. And 59 years is lower than what you’ll see in Iraq or North Korea.

And so, when you have a society where the worst possible health outcomes settle within the same racial caste over and over again, you have to expect that the coronavirus would be no different. When we saw HIV begin with well-off, in particular, white men, now it has become a disease mainly of

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women of color and men of color. Over time, the load that comes from where we live, learn, work, and play takes its health toll. And they come into my emergency department and Raegan’s clinic. By the time the news had picked it up, we’d been seeing it for months. And in fact, it would be amazing if that turned out to be not the case. …

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00:18:25 Thomas Fisher: I remember early on in the coronavirus pandemic, I took care of a 40-something-year-old woman who’d been sick for a week. She had been coughing and febrile and wasn’t able to tolerate much by mouth and was a little bit dehydrated, and she came into the emergency department with the appearance that she’d been working on making sure she looked a certain way all day. She had a full face of makeup, her hair was done, she had on clean clothes and high heeled shoes. And this despite the fact that she’d been in bed for a week because she knew coming in the health care setting, she would be perceived a certain way. And she wanted to be sure that she would get the best possible care despite the fact that she was a part of what is generally the undesirable class: she didn’t have the best insurance, and she was a black woman. In our conversation, she shared a lot of detail about how she couldn’t have gotten the virus because she was doing everything right. She was trying to self-quarantine. Although she had to work, she was taking precautions.

And, to some extent, what she was reflecting is this notion that we’ve applied personal responsibility to all your health outcomes and ignored the fact that she’s a part of a system. She couldn’t quarantine at home because she had to work. She lived in a multi-generational home, and so even if she didn’t have to work, somebody in the house was working.

We tend to hold blameless the systems that we’ve all constructed and instead apply all of the responsibility to an individual to eat right, to follow the right precautions, to use condoms, to not smoke, and we ignore the fact that the system creates situations where, in order to do the right thing for some people, they have to go against the system at all times. They have to avoid all of the winds that blow them into a certain direction. And other people, as long as they go along with the winds that are blowing, they end up with the best possible health outcomes. And so, for people on this call, and particularly the folks who are part of Aspen, they’re shaping those systems.

They are the ones who are doing the hiring and firing. Those are the ones who are upholding or dismantling systems of advantage and disadvantage. These are the folks who have the potential to do more than just simply create gestures and recognize Black Lives Matter now after it’s been a part of society for five

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years, but actually say, “Well, what are the fundamental changes we have to create within our organization so that people like physicians, who want to do the right thing for the right people, do not have to actually go against systems of care, but are following systems of care that create just outcomes?” That’s everybody. That’s not black folks. That’s everybody.

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00:22:13.080 Raegan McDonald-Mosley: What I want to make sure that the folks listening, and I’m so glad that so many people have joined us, take away from this is a bit of an understanding of what we’re talking about when we’re talking about the ways that racism impacts health outcomes. So, very briefly, I want to highlight three ways that racism impacts health outcomes.

There’s been a lot written and said about social determinants of health.

Those are the things outside of the structures and the walls of our health care institution that impact people’s health, so where they live, what they have access to in terms of food, healthy food options, is there green space for them to exercise, do they have health insurance, do they have access to transportation. And there’s a lot that’s been said about how those social determinants of health impact people’s health outcomes and is impacting the COVID outcomes, but there isn’t as much said about why and how those things, if you look at the root cause of those things, is all about racism and policies that have been put in place: red lining that have caused segregation in our communities; highways that have been put in place just completely separate black and white communities; how our education system is funded.

All of those things are deliberate policies that have been put in place that are causing worse outcomes. So I think that’s really important to mention.

In addition to those structural determinants of health that are caused by racist policies, there’s differential treatment from the medical community, and this is also playing itself out in COVID. There was an early study in April, I believe, in seven states that showed that, when white people and black people went to the emergency room with the same symptoms—cough, whatever—things related to COVID-19, black people were six times less likely to be offered a test. Same symptoms, same places, same states. Six times less likely to be offered a test. And that has downstream effects because those people go back to their communities without knowing whether or not they have the virus, and they can’t make educated decisions about whether or not to isolate themselves. They may not have the ability to not go to work without that note from their doctor saying you had a COVID test or you have COVID, so differential treatment by the health care system. And a lot

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of that is based on erroneous ideologies that race is biological. Race is not biological. It is a social construct. It is real, and there are biological impacts, but race itself is not biological, and I think that’s really important for people to understand.

And then lastly, this concept that is well studied now and written about, but not as well known called allostatic load or weathering, which is really just the idea that we as human beings are evolutionarily designed to have a fight or flight response. Where we’re being chased by a bear, our cortisol goes up, and that’s good in that moment. It will help us outrun the bear. But it is not healthy or normal to have an elevated cortisol level at all times, chronically.

But that is the experience of black and brown people walking through our world, that we’re sort of navigating these situations that constantly make us have elevated cortisol hormone levels. Whether that’s just going to the grocery store and being followed because I have my bags with me and I’m trying to be a good environmentalist but someone is worried that I’m going to be stealing groceries, or driving around and being worried about the cops pulling me over and that could lead to loss of life. So this constant chronic elevated cortisol level can lead to dysregulation of hormones, damage to DNA, and cause premature aging and decreased ability to fight disease.

So this is what we’re talking about, the ways that racism shows up and impacts health outcomes from social determinants of health, unfair treatment by the health care system rooted in the erroneous ideology that race is biological, and then just the chronic stress of navigating the world in a brown or black body. That is what’s happening. And that’s what’s playing out here with the COVID crisis. …

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00:27:32 Maria Hinojosa: There’s other ways in which we can take this moment of COVID pandemic, uprising, people of color, racism, and engaging on our own. So what does that look like? Is it on the streets? Is it in the health care system? What does it look like for you when you’re thinking about this?

Thomas Fisher: I think it’s all of the above. I think that so long as we have a system that is designed to harm, every individual action that’s sending somebody a life raft or changes their opportunity for health care or saves them from a bad situation is worth doing and must be done. And I think that, to build on what Raegan described, all of these different variables require a totally different way of conceptualizing our health care system.

It’s not simply that we can optimize around outcomes because our system is optimized and these are the outcomes. We actually need to think about a fundamentally different sort of system that has a foundation that is not

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our current foundation. I’ve been a doctor for about 20 years now. And in that time I’ve seen HIV go from a death sentence to a chronic disease. I’ve seen hepatitis C cured. I’ve seen cervical cancer on the verge of cure with a new vaccine. I’ve seen EMRs make things more efficient. Things have changed because we’re working on optimizing the system. But those aren’t the solutions that are going to change that disability rate in Washington Park from 15% to 3%.

Right now, we often see profit and people in opposition in the setting of health care, where doing the right thing for a person also loses an organization money. So long as that is in conflict, we elevate capital over humanity, and that can never be the case in the setting of health care. We are not producing shoes.

We’re saving people’s lives. And so, that fundamental reconceptualization is what’s required in order for us to get to a place where those issues that Raegan described are no longer the issues. And that is where we all play a part. That’s where we march in the streets and say, “No, we can’t just pretend to improve our EMRs and that’s going to solve our health disparities, when we have a setting that is grinding people into a pulp every day.” Where we have to institute VIP care to get people around these systems that harm them, and where we each have a responsibility right now to try to save folks lives, we get tired. It creates a cognitive dissonance within providers, where every day, they see people falling through the cracks that we can’t save every day, and we need a new system in order to make it safer for both the providers, but also, most importantly, our patients. …

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00:32:39 Raegan McDonald-Mosley: So although I know I laid some really heavy foundation in thinking about all the ways that racism is impacting the health care system, I also want to point out that this is actually good news, because previously we were walking around thinking, “There’s some magical thing in our biology or in our DNA that made us black or made us Latinx, and, therefore, made us have these bad health outcomes.” And that would be terrible if that were the case because we can’t fix that. I woke up black today, I’m going to wake up black tomorrow. My children are black. That is my reality. We can’t change that. But what we can change are all of the things in the systems that are in place that are making these outcomes bad. We can change the world. We can change our health care system so that when two people come in with the same symptoms, that they’re treated the same and have the same likelihood of getting a test. We can change that they have the same likelihood of getting admitted to the high-level service. We can change who gets a ventilator. We can change those things. And I think the fact that our men and women right on the front lines of the health care system are

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seeing this, it’s tangible, it is imprinted in their brains. I think this is going to force us to really face this and change our systems in a very different way than the really sort of subtle outcomes that were happening that we really had to look for before, but now it’s overt and obvious and right in front of us.

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00:35:21 Thomas Fisher: I think there’s a lot of energy put into the role of implicit bias and implicit bias training in improving health care and health care outcomes.

And I think that it is a player in the physician-patient relationship, but not the lead driver. When you look at the people who get tested, so much of it has to do with things that have happened way before they enter that physicianpatient relationship.

Most settings at the beginning of the epidemic had only a handful of tests available, and they were being allocated to special people who had a particular relationship with those that had resources, those that were affiliated with a clinic or medical center that had a ton of resources, or were able to use political and social capital in order to gain access to those resources.

Those decisions were being made in hiring decisions that provided people access to good insurance and getting access to university medical centers as opposed to clinics that might not have those same resources. These are about the way we’ve structured society that even got you to the point where you had the potential to get a test. Once you’re in the setting of a test, there were a lot of rules that were being put in place to allocate those. Some of those that had been put in place already, but others were, “Are you sick enough to be admitted?” If you were sick enough to be admitted at the beginning, you were getting a test. If you were not sick enough to get admitted, it didn’t matter who you were, there weren’t tests available unless you had one of those back doors.

I am skeptical of educational interventions to unravel systemic issues, whether the education is on the individual, the leadership structure, or anywhere in between. It puts the onus again on an individual to work against the system rather than reshaping the system in order to create one that’s more equitable and safe. And so, sure implicit bias training is great because it makes individuals more aware of who they are and more effective in their ability to deliver care. But that remains powerless if the entire system is structured to force you into a decision pathway that is contrary to what your own biases and awareness may imply.

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00:37:44 Raegan McDonald-Mosley: I think I’d like to quickly circle back to the question about race as a social construct. And the reason why is, I feel like we can’t get to that last question, which was, “What would a health care system look like without racism?” until people wrap their minds around this. And I also want to recognize that we, especially those of us who are physicians or work in the health care space, it has been ingrained in us and in our training that race is biological. And guess what, that is completely wrong. So, race is real but is not biological. It is not genetic. There’s as much genetic diversity between races as there are within races.

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00:40:11 Thomas Fisher: There’s so much energy and effort in the health care system to look under the skin, into a cell, into a molecule to find the answer when the answers are obvious and around us in society. And that is a much more challenging problem to solve. And so, we look away. Also, because we as doctors and as individuals are implicated in the construction of our society.

Whereas, we’re not implicated in what’s in that cell or what’s in that molecule.

One of the things I saw related to COVID was, “Oh, vitamin D must be a driver for this.” Well, I’ve heard vitamin D as a driver for all things: the cancer disparities, the HIV disparities, now the COVID disparities. The lack of vitamin D, which brown people will have less of, because it’s partially created by our exposure to sun and so melanin is protective against some things and also limits the production of vitamin D. And when you have obvious answers around us and we’re continuing to look at the molecular level, or as Raegan said, construct race out of thin air, as opposed to focus on what is actually the driver, which is racism, it lets us all off the hook. Rather than forcing us, as physicians, to be engaged in our societal challenges that lead people into our care and also create situations where we’re unable to solve their issues.